Smoking and timing of cessation: impact on pulmonary complications after thoracotomy

Guidelines for preoperative pulmonary function assessment in patients with lung cancer who will undergo surgery (The Japanese Association for Chest Surgery)

This article translates the guidelines for preoperative pulmonary function assessment in patients with lung cancer who will undergo surgery, established by the Japanese Association of Chest Surgery on May 17, 2021, from Japanese to English. The last version of these guidelines was created on April 5, 2011. Over the past decade, changes in clinical practice have occurred that do not align with the current guidelines, prompting a revision in conjunction with the introduction of new evidence this time. This guideline was developed with reference to the internationally adopted GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. Extraction of evidence, systematic review, and quality assessment are entrusted to each guideline review committee and the Pulmonary Function Assessment Working Group. Committee members are also responsible for determining the selection of evidence and the extraction period, with a particular emphasis on adopting items considered to be of special importance. The recommended assessment and management is categorized into a general overview, pulmonary function assessment, cardiopulmonary exercise test, pulmonary function assessment for lung cancer with interstitial pneumonia, preoperative smoking cessation, and pulmonary rehabilitation. These are described by the strength of recommendation, the strength of evidence, and the consensus rate.

Smoking and Complications After Cancer Surgery: A Systematic Review and Meta-Analysis

Importance

Surgical cancer treatments may be delayed for patients who smoke over concerns for increased risk of complications. Quantifying risks for people who had recently smoked can inform any trade-offs of delaying surgery.

Objective

To investigate the association between smoking status or smoking cessation time and complications after cancer surgery.

Data Sources

Embase, CINAHL, Medline COMPLETE, and Cochrane Library were systematically searched for studies published from January 1, 2000, to August 10, 2023.

Study Selection

Observational and interventional studies comparing the incidence of complications in patients undergoing cancer surgery who do and do not smoke.

Data Extraction and Synthesis

Two reviewers screened results and extracted data according to the Meta-Analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Data were pooled with a random-effects model and adjusted analysis was performed.

Main Outcomes and Measures

The odds ratio (OR) of postoperative complications (of any type) for people who smoke currently vs in the past (4-week preoperative cutoff), currently smoked vs never smoked, and smoked within shorter (2-week cutoff) and longer (1-year cutoff) time frames.

Results

The meta-analyses across 24 studies with a pooled sample of 39 499 participants indicated that smoking within 4 weeks preoperatively was associated with higher odds of postoperative complications compared with ceasing smoking for at least 4 weeks (OR, 1.31 [95% CI, 1.10-1.55]; n = 14 547 [17 studies]) and having never smoked (OR, 2.83 [95% CI, 2.06-3.88]; n = 9726 [14 studies]). Within the shorter term, there was no statistically significant difference in postoperative complications between people who had smoked within 2 weeks preoperatively and those who had stopped between 2 weeks and 3 months in postoperative complications (OR, 1.19 [95% CI, 0.89-1.59]; n = 5341 [10 studies]), although the odds of complications among people who smoked within a year of surgery were higher compared with those who had quit smoking for at least 1 year (OR, 1.13 [95% CI, 1.00-1.29]; N = 31 238 [13 studies]). The results from adjusted analyses were consistent with the key findings.

Conclusions and Relevance

In this systematic review and meta-analysis of smoking cessation and complications after cancer surgery, people with cancer who had stopped smoking for at least 4 weeks before surgery had fewer postoperative complications than those smoking closer to surgery. High quality, intervention-based evidence is needed to identify the optimal cessation period and inform clinicians on the trade-offs of delaying cancer surgery.

Timing effects of short-term smoking cessation on lung cancer postoperative complications: a systematic review and meta-analysis

BACKGROUND

Preoperative smoking cessation may reduce postoperative complications in patients with lung cancer. However, the optimal duration of short-term preoperative smoking cessation remains unclear.

METHODS

Three databases, PubMed, Embase, and the Cochrane Library, were searched for studies published up to April 5, 2024. The Newcastle-Ottawa scale was used to assess the risk of bias. The included studies compared the incidence of postoperative complications between patients with different preoperative smoking cessation times and those with persistent preoperative smoking. A meta-analysis of postoperative complications and events such as pneumonia was performed in patients with lung cancer.

RESULTS

Fourteen studies met the inclusion criteria and included a total of 50,741 patients who had undergone pulmonary resection. The meta-analysis showed that preoperative smoking cessation of > 2 weeks and < 1 month did not reduce the incidence of postoperative complications (odds ratio [OR] 1.05; 95% confidence interval [CI] 0.76-1.44; P = 0.78) and pneumonia (OR 0.98; 95% CI 0.60-1.61; P = 0.95). Moreover, preoperative smoking cessation for > 1 month was effective in reducing the incidence of postoperative complications (OR 0.72; 95% CI 0.63-0.83; P < 0.01) as well as pneumonia (OR 0.80; 95% CI 0.49-1.33; P = 0.40).

CONCLUSIONS

This meta-analysis suggests that preoperative smoking cessation for > 1 month is effective in reducing complications and pneumonia after pulmonary resection in patients with lung cancer, especially as video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery become more common.

Smoking cessation assistance among pneumologists and thoracic surgeons in Switzerland: a national survey

Objective

Smoking, with a prevalence of about 25%-30% in Switzerland, is proven to cause major systemic, avoidable diseases including lung cancer, increasing societies morbidity and mortality. Diverse strong quitting smoking recommendations have been made available providing advice facilitating smoking cessation globally. In other European countries like Germany, clinical practice guidelines for smoking cessation services have been implemented. However, in Switzerland, there is still no national consensus on a comprehensive smoking cessation program for lung cancer patients nor on the adequate provider. Our primary aim was to assess the current status of smoking cessation practice among specialists, mainly involved in lung cancer care, in Switzerland in order to uncover potential shortcomings.

Material and methods

A self-designed 14-items questionnaire, which was reviewed and approved by our working group consisting of pneumologists and thoracic surgeons, on demographics of the participants, the status of smoking cessation in Switzerland and specialists' opinion on smoking cessation was sent to thoracic surgeons and pneumologists between January 2024 and March 2024 via the commercially available platform www.surveymonkey.com. Data was collected and analysed with descriptive statistics.

Results

Survey response rate was 22.25%. Smoking cessation was felt to positively affect long term survival and perioperative outcome in lung cancer surgery. While 33 (37.08%) physicians were offering smoking cessation themselves usually and always (35.96%), only 12 (13.48%) were always referring their patients for smoking cessation. Patient willingness was clearly identified as main factor for failure of cessation programs by 63 respondents (70.79%). Pneumologists were deemed to be the most adequate specialist to offer smoking cessation (49.44%) in a combination of specialist counselling combined with pharmaceutic support (80.90%).

Conclusion

The development of Swiss national guidelines for smoking cessation and the implementation of cessation counselling in standardized lung cancer care pathways is warranted in Switzerland to improve long-term survival and perioperative outcome of lung cancer patients.

Postoperative Tobacco Cessation Improves Quality of Life, Lung Function and Long-Term Survival in Non-Small-Cell Lung Cancer Patients

OBJECTIVES

About 90% of all non-small cell lung cancer (NSCLC) cases are associated with inhalative tabacco smoking. Half of patients continue smoking during lung cancer therapy. We examined the effects of postoperative smoking cessation on lung function, quality of life (QOL) and long-term survival.

MATERIALS AND METHODS

In total, 641 patients, who underwent lobectomy between 2012 and 2019, were identified from our single institutional data base. Postoperatively, patients that actively smoked at the time of operation were offered a structured 'smoking cessation' program. For this retrospective analysis, two patient groups (total n = 90) were selected by pair matching. Group A (n = 60) had no postoperative tobacco smoking. Group B (n = 30) involved postoperative continued smoking. Lung function (FEV1, DLCO) and QOL ('SF-36' questionnaire) were measured 12 months postoperatively. We compared long-term outcomes using Kaplan-Meier curves.

RESULTS

The mean age in group A was 62.6 ± 12.5 years and that in group B was 64.3 ± 9.7 years (p = 0.82); 64% and 62%, respectively, were male (p = 0.46). Preoperative smoking habits were similar ('pack years': group A, 47 ± 31; group B, 49 ± 27; p = 0.87). All relevant baseline characteristics we collected were similar (p > 0.05). One year after lobectomy, FEV1 was reduced by 15% in both groups (p = 0.98). Smoking cessation was significantly associated with improved DLCO (group A: 11 ± 16%; group B: -5 ± 14%; p <0.001) and QOL (vitality (VT): +10 vs. -10, p = 0.017; physical role function (RP): +8 vs. -17, p = 0.012; general health perceptions (GH): +12 vs. -5, p = 0.024). Patients who stopped smoking postoperatively had a significantly superior overall survival (median survival: 89.8 ± 6.8 [95% CI: 76.6-103.1] months vs. 73.9 ± 3.6 [95% CI: 66.9-80.9] months, p = 0.034; 3-year OS rate: 96.2% vs. 81.0%, p = 0.02; 5-year OS rate: 80.0% vs. 64.0%, p = 0.016). The hazard ratio (HR) was 2.31 [95% CI: 1.04-5.13] for postoperative smoking versus tobacco cessation.

CONCLUSION

Postoperative smoking cessation is associated with improved quality of life and lung function testing. Notably, a significant increase in long-term survival rates among non-smoking NSCLC patients was observed. These findings could serve as motivation for patients to successfully complete a non-smoking program.

Smoking Cessation for Preoperative Optimization

Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

Offering lung resection to current smokers: An opportunity for more equitable care

OBJECTIVE

Minority patients with lung cancer are less likely to undergo surgical resection and experience worse survival than non-Hispanic White patients. Currently, 40% of thoracic surgeons require smoking cessation before surgery, which may disproportionately affect minority patients. Our objective was to assess the risk of smoking status on postoperative morbidity and mortality among patients with lung cancer.

METHODS

A prospectively maintained institutional database was queried for all patients who underwent surgical resection of a primary lung malignancy between 2006 and 2020. Operative mortality, major morbidity, and a composite of morbidity and mortality were compared between current smokers and prior smokers.

RESULTS

A total of 601 patients underwent resection, and 236 (39.3%) were current smokers. Current smokers were more likely to be younger (P < .01), to have a greater pack-years history (P = .03), and to have worse pulmonary function test results (P < .01). Pretreatment stage, surgical approach, and extent of resection were similar between groups. There was no difference in operative mortality (0.9% vs 1.9%, P = .49), major morbidity (12.7% vs 9.3%, P = .19), or composite major morbidity and mortality between groups (13.1% vs 9.3%, P = .14). After adjusting for pulmonary function status, current smoking status was not associated with mortality or major morbidity on multivariable logistic regression (odds ratio, 1.51; 95% confidence interval, 0.76-3.03, P = .24).

CONCLUSIONS

Current smokers experienced similar rates of mortality and major morbidity as prior smokers. In the context of continued racial and ethnic disparities in lung cancer survival, in particular decreased resection rates among minorities, smoking cessation requirements should not delay or prevent operative intervention for lung cancer.

The Effect of Smoking on the Fusion Rate of Spinal Fusion Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To conduct a systematic review and meta-analysis comparing the fusion rate after spinal fusion surgery between smokers and nonsmokers.

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science electronic databases through March 10, 2021 for cohort and case-control studies assessing the effect of smoking on the fusion rate of spinal fusion surgery. Two researchers independently screened the literature and extracted data according to the inclusion and exclusion criteria. Statistical analysis was performed using RevMan, version 5.4.

RESULTS

A total of 26 studies, including 4 case-control studies and 22 cohort studies, with 4409 patients, were included in the present meta-analysis. Follow-up was at least 6 months. Overall, the pooled results demonstrated that the fusion rate of smokers after spinal fusion was significantly lower than that of nonsmokers. The odds ratio (OR) was 0.55 (95% confidence interval [CI] 0.45-0.67, P < 0.0001). Subgroup analyses by fusion level showed the adverse effect of smoking on the fusion rate at single level (OR 0.61, 95% CI 0.41-0.91, P = 0.02) was more significant than that of multiple levels (OR 0.55, 95% CI 0.38-0.80, P = 0.0010). Subgroup analysis according to the type of bone graft revealed an apparent association between smoking and fusion rate in the autograft subgroup (OR 0.47, 95% CI 0.33-0.66, P < 0.0001) but not in the allograft subgroup (OR 0.69, 95% CI 0.47-1.01, P = 0.06).

CONCLUSIONS

The fusion rate of smokers is significantly lower than that of nonsmokers in spinal fusion surgery. Smokers should be encouraged to quit smoking to improve the outcome of spinal fusion surgery.

Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine

Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use-associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify "at-risk" individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use.

Preoperative Cumulative Smoking Dose on Lung Cancer Surgery in a Japanese Nationwide Database

BACKGROUND

Smoking is a known risk factor for postoperative mortality and morbidity. However, the significance of cumulative smoking dose in preoperative risk assessment has not been established. We examined the influence of preoperative cumulative smoking dose on surgical outcomes after lobectomy for primary lung cancer.

METHODS

A total of 80,989 patients with primary lung cancer undergoing lobectomy from 2014 to 2016 were enrolled. Preoperative cumulative smoking dose was categorized by pack-years (PY): nonsmokers, PY = 0; light smokers, 0 < PY < 10; moderate smokers, 10 ≤ PY < 30; and heavy smokers, 30 ≤ PY. The risk of short-term outcomes was assessed according to PY by multivariable analysis adjusted for other covariates.

RESULTS

Postoperative 30-day mortality, as well as pulmonary, cardiovascular, and infectious complications, increased with preoperative PY. Multivariable analysis revealed that the odds ratios (ORs) for postoperative mortality compared with nonsmokers were 1.76 for light smokers (P = .044), 1.60 for moderate smokers (P = .026), and 1.73 for heavy smokers (P = .003). The ORs for pulmonary complications compared with nonsmokers were 1.20 for light smokers (P = .022), 1.40 for moderate smokers (P < .001), and 1.72 for heavy smokers (P < .001). Heavy smokers had a significantly increased risk of postoperative cardiovascular (OR, 1.26; P = .002) and infectious (OR, 1.39; P = .007) complications compared with nonsmokers.

CONCLUSIONS

The risk of mortality and morbidity after lung resection could be predicted according to preoperative cumulative smoking dose. These findings contribute to the development of strategies in perioperative management of lung resection patients.

Does short-term cessation of smoking before lung resections reduce the risk of complications?

Background

Smoking cessation is a highly important preparation before thoracic surgery. We examined the effects of short-term smoking cessation intervention before pulmonary resection on postoperative pulmonary complications (PPCs).

Methods

A retrospective analysis of prospectively collected data was performed for 753 patients who underwent curative surgical resection for thoracic malignancy at 3 institutions. Patients with a smoking history were instructed to quit smoking. After confirming smoking cessation by at least four weeks before surgery, surgical resection was performed. Subjects were classified into three groups based on their smoking status: abstainers (anyone who had stopped smoking for at least 4 weeks but less than 2 months), former smokers (anyone who had abstained from smoking for more than two months prior to surgery), and never smokers (those who had never smoked). We examined the relationship between the preoperative smoking status and PPCs.

Results

Surgery was performed for 660 primary lung cancers and 93 metastatic lung tumors. The smoking statuses were classified as follows: abstainers (n=105, 14%), former smokers (n=361; 48%) and never smokers (n=287, 38%). The incidence of PPCs among abstainers, former smokers and never smokers was 15%, 8% and 6%, respectively (P=0.01). The mean duration of post-operative chest tube drainage among abstainers, former smokers and never smokers was 3.2, 2.2 and 2.2 days, respectively (P=0.04). The mean post-operative hospital stay among abstainers, former smokers and never smokers was 12.1, 10.6 and 10.2 days, respectively (P=0.07). There was no 30-day mortality in the cohort.

Conclusions

Short-term smoking cessation intervention did not enough reduce the PPCs as much as in former or never smokers.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Quality of smoking cessation advice in guidelines of tobacco-related diseases: An updated systematic review

Tobacco smoking is a major risk factor for a wide range of diseases, and smoking cessation significantly reduces these risks. Clinical guidelines for diseases associated with smoking should therefore include guidance on smoking cessation. This review updated evidence on the proportion of clinical guidelines that do so. We conducted a systematic review investigating clinical guidelines and recommendations developed by UK national or European transnational medical specialty associations and societies between January 2014 and October 2019 on 16 diseases to be at least twice as common among smokers than non-smokers. Outcomes of interest were the reporting of smoking as a risk factor, and the inclusion either of smoking cessation advice or referral to other cessation guidance. We compared our findings with an earlier review of guidelines published between 2000 and 2013. We identified 159 clinical guidelines/recommendations. Over half (51%) made no mention of smoking, while 43% reported smoking as a risk factor for the development of the disease, 31% recommended smoking cessation and 19% provided detailed information on how to deliver smoking cessation support. These proportions were similar to those in our earlier review. Smoking cessation continues to be neglected in clinical management guidance for diseases caused by smoking.

"Are We Gonna Talk About It or Not?" Thoracic Oncology Provider Perspectives on Smoking Cessation

BACKGROUND

Tobacco use is the greatest preventable cause of death and disease in the United States. Despite recommendations from the Centers for Disease Control and Prevention, United States Preventive Task Force, and major professional societies that all health-care providers provide smoking-cessation counseling, smoking-cessation interventions are not consistently delivered in clinical practice. We sought to identify important barriers and facilitators to the utilization of smoking-cessation interventions in a thoracic oncology program.

MATERIALS AND METHODS

We conducted 14 semistructured interviews with providers including thoracic surgeons (n = 3), interventional pulmonologists (n = 1), medical oncologists (n = 3), radiation oncologists (n = 2), and nurses (n = 5). Interviewees were asked about prior and current smoking-cessation efforts, their perspectives on barriers to successful smoking cessation, and opportunities for improvement. Responses were analyzed inductively to identify common themes.

RESULTS

All interviewees report discussing smoking cessation with their patients and realize the importance of a smoking-cessation counseling; however, smoking-cessation interventions are inconsistent and often lacking. Providers emphasized five domains that impact their delivery of smoking-cessation interventions: patient willingness and motivation to quit, clinical engagement and follow-up, documentation of smoking history, provider education in smoking cessation, and the availability of additional smoking-cessation resources.

CONCLUSIONS

Providers recognize the need for more efficient and consistent smoking-cessation interventions. Therefore, the development of interventions that address this need would not only be easily taught to providers and delivered to patients but also be welcomed into clinics.

Perioperative complications of abdominal surgery in smokers

Purpose

This study examined the association between smoking and perioperative complications of laparoscopic abdominal surgery and whether these complications were reduced with ≥ 4 weeks of preoperative smoking cessation.

Methods

A total of 555 patients who underwent gastric and colorectal cancer surgeries under general anesthesia were divided into the following groups retrospectively: 290 individuals without smoking history (NS group), 144 previous smokers (stopped smoking more than 8 weeks before surgery, PS group), and 121 current smokers (CS group) divided to two groups according to preoperative smoking cessation for < 4 (CS1, n = 76) and 4–8 weeks (CS2, n = 45).

Results

When compared with the NS group, postoperative hospitalization duration was significantly longer in the CS1 group (p < 0.01), whereas differences between the CS2 or PS groups and NS group were not significant. The total number of postoperative complications was higher in all groups of smoking than in NS group, independent on preoperative smoking cessation; however, suture failure was significantly more frequent only in CS1 group. Although pack-years did not significantly affect complication rates in smokers, duration of smoking cessation time in PS group was a negative predictor of postoperative complications.

Conclusion

Providing more than 4 weeks of smoking cessation before gastrointestinal surgery can reduce the duration of hospitalization and rate of suture failure.

[Preconditioning of the lungs and circulation before visceral and thoracic surgical interventions]

BACKGROUND

Estimation of the perioperative risk plays a decisive role in the surgical indications, particularly in view of the demographic change. For this reason, prehabilitation concepts for reducing perioperative risk nowadays play an increasingly important role.

OBJECTIVE

Presentation of the current recommendations for preoperative diagnostics in thoracic surgical interventions as well as existing prehabilitation concepts and their practical applicability.

MATERIAL AND METHODS

A selective review of the literature was carried out by searching the electronic databases PubMed, Cochrane Library and ISRCTN, including the guidelines of the American College of Chest Physicians (ACCP) and the European Society of Thoracic Surgery (ESTS).

RESULTS

Preconditioning includes the conservative treatment of underlying diseases, smoking cessation and prehabilitation. Prehabilitation is an increasingly pressing concept in routine clinical practice, even though the evidence is limited due to the very heterogeneous study situation. Overall, however, there is a tendency for positive effects on the quality of life and postoperative complications as well as convalescence.

CONCLUSION

In addition to preoperative diagnostics to assess the perioperative risk, effective preconditioning of patients is also necessary. For this an interdisciplinary approach including anesthesia, pneumology, psychotherapy and physiotherapy is necessary. In addition to the conservative medicinal optimization, prehabilitation concepts are gaining in importance and will certainly become established in routine clinical practice. From the surgical perspective, minimally invasive approaches and parenchyma-sparing resections also serve to reduce risks.

Impact of smoking history on postoperative complications after lung cancer surgery - a study based on 286 cases

Aim

The aim of the study was to evaluate the impact of smoking cessation and its timing in the preoperative period on postoperative morbidity in patients undergoing surgery for non-small cell lung cancer (NSCLC).

Material and methods

Two hundred and eighty-six patients surgically treated for NSCLC were prospectively analyzed in terms of duration and intensity of smoking, time period from smoking cessation to surgery, and postoperative morbidity. The patients were divided into five groups: I – current smokers and past smokers who quit smoking less than 2 weeks before surgery (n = 67), II – past smokers who quit 2 weeks to 3 months (n = 106), III – past smokers who quit 3 months to 1 year (n = 30), IV – past smokers who quit more than 1 year (n = 71), V – never smokers (n = 12).

Results

In the analyzed group 95.8% were smokers or past smokers. Postoperative complications occurred in 40.2% of patients including pulmonary (21.3%) and cardiac morbidity (17.8%). The pulmonary and circulatory morbidity rates were the lowest in group V but the differences were not significant. Similarly, there were no significant differences between groups with and without pulmonary or circulatory complications regarding: number of daily smoked cigarettes, smoking duration and the moment of cessation. The analysis of segmental regression showed the smallest percentage of complications in patients who quit smoking between the 8^th and the 10^th week before the operation.

Conclusions

Among patients surgically treated for NSCLC, duration of smoking and number of smoked cigarettes has no significant influence on frequency and type of postoperative complications. The best moment to quit smoking is the period between the 8^th and the 10^th week preceding surgery.

Thoracic Surgeons' Beliefs and Practices on Smoking Cessation Before Lung Resection

BACKGROUND

Smoking is a risk factor for complications after lung resection. Our primary aim was to ascertain thoracic surgeons' beliefs and practices on smoking cessation before lung resection.

METHODS

An anonymous survey was emailed to 846 thoracic surgeons who participate in The Society of Thoracic Surgeons General Thoracic Surgery Database.

RESULTS

The response rate was 23.6% (n = 200). Surgeons were divided when asked whether it is ethical to require that patients quit smoking (yes, n = 96 [48%]) and whether it is fair to have their outcomes affected by patients who do not quit (yes, n = 87 [43.5%]). Most do not require smoking cessation (n = 120 [60%]). Of those who require it, the most common required period of cessation is 2 weeks or more. Most believe that patient factors are the main barrier to quitting (n = 160 [80%]). Risk of disease progression (39% vs 17.5%, p = 0.02) and alienating patients (17.5% vs 8.8%, p = 0.04) were very important considerations of those who do not require smoking cessation versus those who do. Only 19 (9.5%) always refer to a smoking cessation program and prescribe nicotine replacement therapy and even fewer, 9 (4.5%), always refer to a program and prescribe medical therapy.

CONCLUSIONS

Thoracic surgeons are divided on their beliefs and practices regarding smoking cessation before lung resection. Most believe patient factors are the main barrier to quitting and have concerns about disease progression while awaiting cessation. Very few surgeons refer to a smoking cessation program and prescribe nicotine replacement therapy or medical therapy.

The Need to Prioritize and Re-prioritize Palliative Care Options: Smoking Cessation as a Case-in-Point

OPINION STATEMENT

Palliative care in cancer patients requires a continuous reprioritization of effort. This review describes the need for this reprioritization and uses smoking cessation as a case-in-point. The treatment of patients with metastatic non-small cell lung cancer has changed dramatically in the past few years. Interestingly, patients who had previously smoked now have an improved prognosis-for a variety of reasons. This review discusses this last observation in detail and raises the question of how forcefully we should advise smoking cessation in patients with incurable metastatic non-small cell lung cancer.

Optimizing health before elective thoracic surgery: systematic review of modifiable risk factors and opportunities for health services research

Despite progress in many different domains of surgical care, we are still striving toward practices which will consistently lead to the best care for an increasingly complex surgical population. Thoracic surgical patients, as a group, have multiple medical co-morbidities and are at increased risk for developing complications after surgical intervention. Our healthcare systems have been focused on treating complications as they occur in the hopes of minimizing their impact, as well as aiding in recovery. In recent years there has emerged a body of evidence outlining opportunities to optimize patients and likely prevent or decrease the impact of many complications. The purpose of this review article is to summarize four major domains-optimal pain control, nutritional status, functional fitness, and smoking cessation-all of which can have a substantial impact on the thoracic surgical patient's course in the hospital-as well as to describe opportunities for improvement, and areas for future research efforts.

Pre-operative pulmonary assessment and risk factors for post-operative pulmonary complications in elective abdominal surgery in Nigeria

BACKGROUND AND OBJECTIVES

Post-operative pulmonary complications (PPCs) are recurring causes of rising morbidity and mortality in surgeries. This study sought to evaluate pre-operative risk factors for PPCs in abdominal surgerypatients in Nigeria.

METHODOLOGY

This was a prospective study in patients booked for surgery in 2014. Biodata, medical his tory, pre-operative respiratory and cardiovascular examination findings, body mass index, serum albumin, serum urea, ventilatory function, chest x-rays and oxygen saturation were obtained. The association between pre-operative variables and PPCs was determined.

RESULTS

The pre-operative spirometry was predominantly restrictive (62%). Overall, the prevalence of PPCs was 52%. This included non-productive cough (14%), isolated productive cough (10%), productive cough with abnormal chest finding (16%), pneumonia (8%), pleural effusion (5%), ARDS (2%). Percentage predicted FEV1 and FVC were lower in participants with PPCs. (p= 0.03 and p=0.01respectively). Pre-operative cough, shortness of breath and consolidation were associated with PPCs (p< 0.05). Post-operative respiratory rate and pulse rate in participants with PPCs were higher than the values in those without PPCs (p=0.03 and p=0.05).

CONCLUSION

The prevalence of PPCs was high in this study. Pre-operative cough, shortness of breath, consolidation, abnormally low percentage predicted FEV1 and FVC were associated with PPCs.

Impact of previous head and neck cancer on postoperative complications after surgical resection for lung cancer: a case-control study

Background

Head and neck cancer (HNC) and lung cancer are often linked because of common risk factors. We aimed to assess the risk of postoperative complications in patients with previous HNC undergoing thoracic surgery for lung cancer.

Methods

Patients with previous HNC undergoing surgery for lung cancer were included in this retrospective, monocentric, case-control study. All patients were matched for age, sex, FEV₁, smoking history, and year of surgery with lung cancer patients without previous HNC. Major postoperative complication was defined as at least one of the following during the first 30 days post lung resection (LR): death, shock, need for mechanical ventilation, and pneumonia.

Results

From January 2006 to May 2012, 65 patients with previous HNC underwent LR. Fifty-nine of these patients were included and matched with 120 control patients without HNC. Major complications occurred in 25 [42.4% (95% CI, 29.4-55.4%)] vs. 19 [15.8% (95% CI, 9.2-22.5%)] patients in the HNC and non-HNC groups, respectively (P<0.001). Among the complications, pneumonia occurred in 19 (32.2%) vs. 12 (10%) (P=0.01), and death occurred in 5 (8.5%) vs. 2 (1.7%) patients in the HNC and non-HNC groups, respectively (P=0.04). The following factors were identified by multivariate analysis to be independently associated with postoperative complications: previous HNC [odds ratio (OR) =4.24; (95% CI, 1.84-9.74)], male gender [OR =8.99; (95% CI, 1.05-76.78)], cumulative smoking [OR =1.02 per unit; (95% CI, 1.01-1.04)] and elevated Charlson score [OR =1.45; (95% CI, 1.07-1.96)].

Conclusions

Previous HNC is a major independent risk factor for serious postoperative complications after LR for lung cancer. Postoperative pneumonia (POP) is the most frequent complication.

Enhanced recovery pathways in thoracic surgery from Italian VATS Group: preoperative optimisation

Preoperative patient optimisation is a key point of enhanced recovery after thoracic surgery pathways. This could be particularly advantageous when considering video-assisted thoracic surgery (VATS) lobectomy, because reduced trauma related to minimally invasive techniques is one of the main factors favouring improved postoperative outcome. Main specific interventions for clinical optimisation before major lung resection include assessment and treatment of comorbidities, minimizing preoperative hospitalization, optimisation of pharmacological prophylaxis (antibiotic and thromboembolic) and minimizing preoperative fasting. Literature data and clinical evidences in this setting are reported and discussed.

Enhanced recovery after surgery (ERAS) and fast-track in video-assisted thoracic surgery (VATS) lobectomy: preoperative optimisation and care-plans

Main specific interventions for preoperative clinical optimisation of patients undergoing lung cancer surgery include assessment and treatment of comorbidities, minimizing preoperative hospitalization, minimizing preoperative fasting, and optimisation of antibiotic and thrombo-embolic prophylaxis. Preoperative patient optimisation is considered a crucial part of enhanced recovery after thoracic surgery pathways. Potentially, advantages of this fast-track management could be even higher when considering video-assisted thoracic surgery (VATS) major lung resection, because reduced trauma related to minimally invasive techniques is one of the main factors improving postoperative outcome. Literature data and clinical evidences in this setting are reported and discussed.

Predictors and Outcomes of Postoperative Pulmonary Complications following Abdominal Surgery in a South Indian Population

Background

Postoperative pulmonary complications (PPC) following abdominal surgery are associated with increased morbidity and poorer outcomes. We prospectively examined risk factors associated with the development of PPC in patients undergoing abdominal surgery.

Aims

The primary outcome was to determine the association of predefined risk factors in the prediction of PPC after abdominal surgery. Secondary outcomes were evaluation of outcomes of PPC.

Setting and Design

This was a prospective study conducted in the gastrosurgical and urological units of a tertiary care referral hospital in patients undergoing abdominal surgery over a period of 6 months (November 2015-April 2016).

Materials and Methods

Relevant preoperative and intraoperative variables were recorded by the anesthesiologist in a pro forma provided. Postoperatively, data from the Intensive Care Unit (ICU) were collected from data sheets. PPC were defined according to preset criteria and outcomes of the patients including ICU stay, hospital stay, and mortality were noted.

Statistical Analysis

Chi-square test was used to find the association of risk factors of PPC. Mann-Whitney test was used for continuous variables and McNemar's test for postoperative respiratory variables. A final regression analysis was performed with factors with significant association (P < 0.1).

Results

One hundred and fifty patients were included, and 24 patients (16%) developed PPC as defined by our criteria. Emergency surgery (44.4% of PPC) and cardiac comorbidity (23.9% of PPC) were significant associations for pulmonary complications. The length of ICU and hospital stay (LOICU, LOHS) and mortality were higher in the group with pulmonary complications (P < 0.001).

Conclusions

Emergent surgery and cardiac comorbidities were independent predictors for the development of PPC. PPC are associated with increased LOHS, LOICU stay, and mortality.

Refraining from smoking shortly before lobectomy has no influence on the risk of pulmonary complications: a case-control study on a matched population

Objectives

Whether or not smoking increases the risk of postoperative pulmonary complications (PPCs) in lung resection patients remains controversial. The objective of this study was to evaluate whether active smoking at the time of surgery increases the risk of PPCs compared to abstention shortly before the procedure.

Methods

We conducted a case-control study on 378 patients who underwent non-extended lobectomy in our institution. Cases were active smokers at the time of surgery, and controls were patients who quit smoking at any time up to 16 weeks before surgery. All patients received the same perioperative care, including chest physiotherapy. The occurrence of PPCs was the considered outcome. PPCs were defined as pneumonia (American Thoracic Society criteria, 2004) or atelectasis requiring bronchoscopy. Cases and controls were matched according to age, body mass index, forced expiratory volume in the first second of expiration (FEV1%), FEV1/forced vital capacity, type of approach and diagnosis of non-small-cell lung cancer. We calculated the odds ratio (OR) with 95% confidence interval (CI) for PPCs.

Results

The overall prevalence of PPCs was 4.7% (18/378); 5.3% (13 out of 244) in the active smokers group and 3.7% (5 out of 134) in the ex-smokers group. After matching, two sets of 134 patients each were compared. The prevalence was 4.5% (6/134) in active and 3.7% (5/134) in ex-smokers (OR 1.21 95% CI: 0.29-5.13, P  =   0.76).

Conclusions

In this population of patients strictly matched according to risk criteria for PPCs, smoking at the time of surgery was not identified as a risk variable. Therefore, the practice of postponing surgery until tobacco abstention has been achieved does not seem to be justified.

Smoking, Gender, and Overweight Are Important Influencing Factors on Monocytic HLA-DR before and after Major Cancer Surgery

Background

Monocytic human leukocyte antigen D related (mHLA-DR) is essential for antigen-presentation. Downregulation of mHLA-DR emerged as a general biomarker of impaired immunity seen in patients with sepsis and pneumonia and after major surgery. Influencing factors of mHLA-DR such as age, overweight, diabetes, smoking, and gender remain unclear.

Methods

We analyzed 20 patients after esophageal or pancreatic resection of a prospective, randomized, placebo-controlled, double-blind trial (placebo group). mHLA-DR was determined from day of surgery (od) until postoperative day (pod) 5. Statistical analyses were performed using multivariate generalized estimating equation analyses (GEE), nonparametric multivariate analysis of longitudinal data, and univariate post hoc nonparametric Mann–Whitney tests.

Results

In GEE, smoking and gender were confirmed as significant influencing factors over time. Univariate analyses of mHLA-DR between smokers and nonsmokers showed lower preoperative levels (p = 0.010) and a trend towards lower levels on pod5 (p = 0.056) in smokers. Lower mHLA-DR was seen in men on pod3 (p = 0.038) and on pod5 (p = 0.026). Overweight patients (BMI > 25 kg/m²) had lower levels of mHLA-DR on pod3 (p = 0.039) and pod4 (p = 0.047).

Conclusion

Smoking is an important influencing factor on pre- and postoperative immune function while postoperative immune function was influenced by gender and overweight. Clinical trial registered with ISRCTN27114642.

Chronic obstructive pulmonary disease in patients with lung cancer: prevalence, impact and management challenges

Chronic obstructive pulmonary disease (COPD) and lung cancer share a common etiological factor (cigarette smoking) and usually coexist in everyday clinical practice. The prevalence of COPD among newly diagnosed patients with lung cancer sometimes exceeds 50%. COPD is an independent risk factor (2-4 times higher than non-COPD subjects) for lung cancer development. The presence of emphysema in addition to other factors (e.g., smoking history, age) could be incorporated into risk scores in order to define the most appropriate target group for lung cancer screening using low-dose computed tomography. Clinical management of patients with coexistence of COPD and lung cancer requires a multidisciplinary oncology board that includes a pulmonologist. Detailed evaluation (lung function tests, cardiopulmonary exercise test) and management (inhaled drugs, smoking cessation, pulmonary rehabilitation) of COPD should be taken into account for lung cancer treatment (surgical approach, radiotherapy).

Smoking and timing of cessation on postoperative pulmonary complications after curative-intent lung cancer surgery

BACKGROUND

Smoking is a risk factor for postoperative pulmonary complications (PPC) following non-small cell lung cancer (NSCLC) surgery. The optimal timing for preoperative smoking cessation has not been identified. Our study aimed to observe the impact of preoperative smoking cessation on PPC incidence and other postoperative outcomes including long-term survival.

METHODS

A prospective study included consecutive patients following resection for NSCLC in a regional thoracic centre over a 4-year period (2010-2014). Patients were stratified according to self-reported preoperative smoking status. The primary endpoint was PPC incidence, which was assessed from postoperative day one onwards using the Melbourne Group Scale. Secondary endpoints included short-term outcomes (hospital length of stay [LOS], intensive therapy unit [ITU] admission, 30-day hospital readmission rate) and long-term survival.

RESULTS

Four hundred and sixty-two patients included 111 (24%) current smokers, 55 (12%) ex-smokers <6 weeks, 245 (53%) ex-smokers ≥6 weeks and 51 (11%) never smokers. PPC occurred in 60 (13%) patients in total. Compared to never smokers, current smokers had a higher frequency of PPC (22% vs. 2%, p = 0.004), higher frequency of ITU admission (14% vs. 0%; p = 0.001) and a longer median (IQR) hospital LOS (6 [5] vs. 5 [2]; p = 0.001). In the ex-smokers there was a trend for a lower frequency of PPC (<6 weeks, 10.9% vs. ≥6 weeks, 11.8%) and ITU admission (<6 weeks, 5.5% vs. ≥6 weeks, 4.5%), but there was no difference between the <6 weeks or ≥6 weeks ex-smoking groups prior to surgery. There was no significant difference in long-term survival found between the groups of differing smoking status (median follow-up 29.8 months, 95%CI 28.4-31.1).

CONCLUSION

Current smokers have higher postoperative morbidity; this risk reduces following smoking cessation but 6 weeks does not appear to identify a time-point where differences in outcomes are noted.

How Can Smoking Cessation Be Induced Before Surgery? A Systematic Review and Meta-Analysis of Behavior Change Techniques and Other Intervention Characteristics

Background: Smokers who continue to smoke up to the point of surgery are at increased risk of a range of complications during and following surgery.

Objective: To identify whether behavioral and/or pharmacological interventions increase the likelihood that smokers quit prior to elective surgery and which intervention components are associated with larger effects.

Design: Systematic review with meta-analysis.

Data sources: MEDLINE, Embase, and Embase Classic, CINAHL, CENTRAL.

Study selection: Studies testing the effect of smoking reduction interventions delivered at least 24 h before elective surgery were included.

Study appraisal and synthesis: Potential studies were independently screened by two people. Data relating to study characteristics and risk of bias were extracted. The effects of the interventions on pre-operative smoking abstinence were estimated using random effects meta-analyses. The association between specific intervention components (behavior change techniques; mode; duration; number of sessions; interventionist) and smoking cessation effect sizes were estimated using meta-regressions.

Results: Twenty-two studies comprising 2,992 smokers were included and 19 studies were meta-analyzed. Interventions increased the proportion of smokers who were abstinent or reduced smoking by surgery relative to control: g = 0.56, 95% CI 0.32–0.80, with rates nearly double in the intervention (46.2%) relative to the control (24.5%). Interventions that comprised more sessions, delivered face-to-face and by nurses, as well as specific behavior change techniques (providing information on consequence of smoking/cessation; providing information on withdrawal symptoms; goal setting; review of goals; regular monitoring by others; and giving options for additional or later support) were associated with larger effects.

Conclusion: Rates of smoking can be halved prior to surgery and a number of intervention characteristics can increase these effects. There was, however, some indication of publication bias meaning the benefits of such interventions may be smaller than estimated.

Registration: Prospero 2015: CRD42015024733

Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer

Patients undergoing major oncological surgery for head and neck cancer (SHNC) have a particularly high risk of nosocomial infections. We aimed to identify risk factors for ventilator-associated pneumonia (VAP) in patients undergoing SHNC. The study included 465 patients who underwent SHNC between June 2011 and June 2014. The rate of VAP, risk factors for VAP, and biological aspects of VAP were retrospectively evaluated. The incidence of VAP was 19.6% (n = 95) in patients who required more than 48 h of mechanical ventilation. Staphylococcus (37.7%), Enterobacteriaceae (32.1%), Pseudomonas (20.8%), and Haemophilus (16.9%) were the major bacterial species that caused VAP. The independent risk factors for VAP were advanced age, current smoking status, chronic obstructive pulmonary disease, and a higher simplified acute physiology score system II upon admission. Tracheostomy was an independent protective factor for VAP. The median length of stay in the ICU for patients who did or did not develop VAP was 8.0 and 6.5 days, respectively (P = 0.006). Mortality among patients who did or did not develop VAP was 16.8% and 8.4%, respectively (P < 0.001). The potential economic impact of VAP was high because of the significantly extended duration of ventilation. A predictive regression model was developed with a sensitivity of 95.3% and a specificity of 69.4%. VAP is common in patients who are undergoing SHNC and who require more than 48 h of mechanical ventilation. Therefore, innovative preventive measures should be developed and applied in this high-risk population.

Identifying patients at higher risk of pneumonia after lung resection

BACKGROUND

Pneumonia is considered as one of the most common and serious complications after lung resection. The purpose of this study was to identify the risk factors associated with postoperative pneumonia (POP) after lung resection and to develop a scoring system to stratify patients with increased risk of POP.

METHODS

A retrospective review of a prospective database of patients between September 2014 and June 2016 was carried out. Logistic regression analysis was used to examine the risk factors for POP. Bootstrap resampling analysis was used for internal validation. Regression coefficients were used to develop weighted risk scores for POP.

RESULTS

Results revealed that age ≥64 years, smoking (current or previous), high pathological stage, and extent of excision of more than one lobe as risk factors. Logistic regression analysis showed that the predictors of POP were as follows: age ≥64 years, smoking, extent of excision of more than one lobe. A weighted score based on these factors was developed which was follows: smoking (three points), age ≥64 years (four points), and extent of excision of more than one lobe (five points). POP score >5 points offered the best combination of sensitivity (64.7%) and specificity (83.3%), and an area under receiver operating characteristic (ROC) curve (AUC) of 0.830 [95% confidence interval (CI): 0.746-0.914].

CONCLUSIONS

Patients with older age, smoking and extent of excision of more than one lobe have a higher risk for pneumonia after lung cancer surgery. Also, the scoring system helps to guide decision making of POP risk reduction.

Smoking and Risk of Surgical Site Infection after Spinal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

The effect of smoking on the risk of surgical site infection (SSI) after spinal surgery remains controversial. Therefore, we conducted a meta-analysis to determine whether there is an association between smoking and the risk of SSI and to calculate the relative risk of infections attributable to smoking.

METHODS

We performed a literature search of cohort and case-control studies in the MEDLINE, Embase, and ISI Web of Science databases. Sensitivity and subgroup analyses were performed to test the robustness of overall estimates of risk and to investigate potential sources of heterogeneity. We further calculated the population-attributable fraction (PAF) to evaluate the proportion of SSIs associated with smoking.

RESULTS

In total, 26 independent observational studies involving 67,405 patients who underwent spinal surgery were analyzed. Smokers had a significantly higher risk of SSI than did nonsmokers (odds ratio [OR] 1.26; 95% confidence interval [CI] 1.05-1.51). Subgroup analysis according to the study design revealed an apparent association between smoking and SSI in the cohort subgroup (OR 1.40; 95% CI 1.17-1.66), but not in the case-control subgroup (OR 0.99; 95% CI 0.64-1.53). After evaluation of the PAF, the proportion of SSIs associated with smoking increased to 10.37%.

CONCLUSIONS

This meta-analysis demonstrated that smoking increases the risk of SSI after spinal surgery. False-negative associations in other studies may have resulted from defects in the study design. However, because of the heterogeneity among the studies in the present meta-analysis, the results should be interpreted with caution.

Assessment and Optimisation of Lung Cancer Patients for Treatment with Curative Intent

Over the past decade the field of lung cancer management has seen many developments. Coupled with an ageing population and increasing rates of comorbid illness, the work-up for treatments with curative intent has become more complex and detailed. As well as improvements in imaging and staging techniques, developments in both surgery and radiotherapy may now allow patients who would previously have been considered unfit or not appropriate for treatment with curative intent to undergo radical therapies. This overview will highlight published studies relating to investigation and staging techniques, together with assessments of fitness, with the aim of helping clinicians to determine the most appropriate treatments for each patient. We also highlight areas where further research may be required.

Operating on Patients Who Smoke: A Survey of Thoracic Surgeons in the United States

BACKGROUND

Although preoperative smoking is associated with increased postoperative complications in patients who undergo major thoracic surgical procedures, there are no national guidelines that address the patient's preoperative tobacco use. This study examined the typical preoperative management of thoracic surgical patients who are smokers.

METHODS

The link to an anonymous survey was emailed to cardiothoracic surgeons in the United States. The survey included questions regarding the likelihood of a surgeon to offer surgery and strategies used to assist patients in quitting smoking before surgery.

RESULTS

The majority of the 158 surgeons who responded to the survey were general thoracic surgeons (68%, 107 of 158), in an academic practice (57%, 90 of 158), with more than 15 years of experience (51%, 81 of 158). An overwhelming majority of respondents (98.1%, 155 of 158) considered smoking preoperatively a risk factor for postoperative complications. The most common cessation strategy offered to smokers was pharmacologic intervention (77%, 122 of 158). Nearly half of the surgeons (47%, 74 of 156) would not perform certain operations in a patient who was a current smoker, but only 14% (10 of 74) tested patients preoperatively for smoking. Thoracic surgeons (odds ratio 2.1, p = 0.0379) and surgeons in academic practice (odds ratio 1.9, p = 0.057) were more likely to deny certain surgeries to current smokers. Two thirds of the surgeons (66%, 48 of 74) thought that the ideal wait time from smoking cessation to surgery was 2 to 4 weeks.

CONCLUSIONS

There is significant disagreement in the cardiothoracic surgical community regarding how to treat patients who smoke, especially when deciding to deny or postpone surgery. Prospective studies and guidelines are needed.

Smoking status and 30-day mortality in patients undergoing pulmonary resections

BACKGROUND

Smoking status has not been shown to have a significant effect on 30-day mortality after potentially curative resectional surgery for non-small-cell lung cancer, and this is reflected in the guidelines of the National Institute for Health and Care Excellence in the United Kingdom.

METHODS

A validated prospective thoracic surgery database of consecutive patients undergoing potentially curative resection at a single institution was analyzed. Univariate and propensity analyses of 30-day mortality were performed.

RESULTS

Univariate analysis identified 30-day mortality as significantly lower in current smokers (n = 852, 2.6%) than ex-smokers (n = 1587, 4.9%; p < 0.001). Propensity 1:1 matching of male patients resulted in 727 current smokers being matched to 727 ex-smokers. The overall balance test (χ(2 )= 6.1, degrees of freedom = 8, p = 0.6), indicated a good match. After propensity matching, the mortality rate was significantly higher in current smokers (p = 0.01).

CONCLUSIONS

Current smokers and ex-smokers are statistically different with regard to risk factors for death. This results in a skewed population of current and ex-smokers undergoing resection for non-small-cell lung cancer. Development of a risk model for 30-day mortality revealed that current smokers have a lower predicted 30-day mortality than ex-smokers, a finding that is counterintuitive. Propensity matching balanced the current and ex-smoker groups to correct for group differences. Analysis after propensity matching identified current smoking as a significant factor determining 30-day mortality.

[Systematizing support in cessation smoking to improve care for cancer patients]

Approximately 20% of cancer patients smoke at diagnosis (all localizations included), and over two thirds continue despite the therapeutic management of their cancer, especially when cancer is not associated with tobacco. The impact of smoking on quality of care for patients is actually not enough considered. A literature review conducted by the French National Cancer Institute emphasizes the importance of tobacco cessation to improve the prognosis (decreased mortality from all causes and specific); to reduce the risk of second primary cancers; to reduce per- and post-surgical risks as long as some toxicities related to treatments and to improve the quality of physical and mental life of patients. It is important that a communication with the patient takes place at the beginning of the treatment to impact the smoking behavior. All oncology health professionals should deliver a clearly and personalized cessation advice in the light of scientific data and ensure that smoking cessation help will be offered to the patient.

[Consequences of tobacco smoking on lung cancer treatments]

In France, in 2010, tobacco induced 81% of deaths by lung cancer corresponding to about 28,000 deaths. Continued smoking after diagnosis has a significant impact on treatment. In patients with lung cancer, the benefits of smoking cessation are present at any stage of disease. For early stages, smoking cessation decreases postoperative morbidity, reduces the risk of second cancer and improves survival. Previous to surgery, smoking cessation of at least six to eight weeks or as soon as possible is recommended in order to reduce the risk of infectious complications. Tobacco could alter the metabolism of certain chemotherapies and targeted therapies, such as tyrosine kinase inhibitors of the EGF receptor, through an interaction with P450 cytochrome. Toxicity of radiations could be lower in patients with lung cancer who did not quit smoking before treatment. For patients treated by radio-chemotherapy, overall survival seems to be better in former smokers but no difference is observed in terms of recurrence-free survival. For advanced stages, smoking cessation enhances patients' quality of life. Smoking cessation should be considered as full part of lung cancer treatment whatever the stage of disease.

Clinical pathway for thoracic surgery in the United States

The paradigm for postoperative care for thoracic surgical patients in the United States has shifted with efforts to reduce hospital length of stay and improve quality of life. The increasing usage of minimally invasive techniques in thoracic surgery has been an important part of this. In this review we will examine our standard practices as well as the evidence behind both general contemporary postoperative care principles and those specific to certain operations.

Systematic Review of Tobacco Use after Lung or Head/Neck Cancer Diagnosis: Results and Recommendations for Future Research

Tobacco use after cancer diagnosis is associated with adverse cancer outcomes, yet reliable prevalence estimates for this behavior are lacking. We conducted a systematic literature review of the prevalence of current tobacco use among individuals with a history of lung or head/neck cancer (CRD #42012002625). An extensive search of electronic databases (MEDLINE, EMBASE, Cochrane Library, CINAHL, PsycINFO, and Web of Science) identified 7,777 potentially relevant articles published between 1980 and 2014 and 131 of these yielded pertinent information. Aggregating results across heterogeneous study designs and diverse patient samples, the overall mean prevalence rate of current tobacco use (mostly cigarette smoking) was 33.0% (median, 31.0%). Among current tobacco users at cancer diagnosis, the mean prevalence rate of current tobacco use (mostly cigarette smoking) was 53.8% (median, 50.3%). In many cases, an operational definition of "current" tobacco use was absent, and biochemical verification of self-reported smoking status was infrequent. These and other observed methodologic limitations in the assessment and reporting of cancer patients' tobacco use underscore the necessity of uniform tobacco use assessment in future clinical research and cancer care.